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                                    <wp:docPr id="2" name="IM 2"/>
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                                                    <pic:cNvPr id="2" name="IM 2"/>
                                                    <pic:cNvPicPr/>
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                                                <pic:blipFill>
                                                    <a:blip r:embed="rId6"/>
                                                    <a:stretch>
                                                        <a:fillRect/>
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                                                    <a:xfrm>
                                                        <a:off x="0" y="0"/>
                                                        <a:ext cx="1625630" cy="508635"/>
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                                                    <a:prstGeom prst="rect">
                                                        <a:avLst/>
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                    <w:p>
                        <w:pPr>
                            <w:spacing w:line="332" w:lineRule="auto"/>
                            <w:rPr>
                                <w:rFonts w:ascii="Arial"/>
                                <w:sz w:val="21"/>
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                        </w:pPr>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:before="94" w:line="219" w:lineRule="auto"/>
                            <w:ind w:left="3020"/>
                            <w:rPr>
                                <w:rFonts w:hint="eastAsia" w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:sz w:val="29"/>
                                <w:szCs w:val="29"/>
                                <w:lang w:val="en-US" w:eastAsia="zh-CN"/>
                            </w:rPr>
                        </w:pPr>
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                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:b/>
                                <w:bCs/>
                                <w:spacing w:val="23"/>
                                <w:sz w:val="24"/>
                                <w:szCs w:val="24"/>
                            </w:rPr>
                            <w:t>病案复印(复制)</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:hint="eastAsia" w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:b/>
                                <w:bCs/>
                                <w:spacing w:val="23"/>
                                <w:sz w:val="24"/>
                                <w:szCs w:val="24"/>
                                <w:lang w:val="en-US" w:eastAsia="zh-CN"/>
                            </w:rPr>
                            <w:t>申请单</w:t>
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                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:keepNext w:val="0"/>
                            <w:keepLines w:val="0"/>
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                            <w:widowControl/>
                            <w:kinsoku w:val="0"/>
                            <w:wordWrap/>
                            <w:overflowPunct/>
                            <w:topLinePunct w:val="0"/>
                            <w:autoSpaceDE w:val="0"/>
                            <w:autoSpaceDN w:val="0"/>
                            <w:bidi w:val="0"/>
                            <w:adjustRightInd w:val="0"/>
                            <w:snapToGrid w:val="0"/>
                            <w:spacing w:before="176" w:line="360" w:lineRule="auto"/>
                            <w:ind w:left="170"/>
                            <w:textAlignment w:val="baseline"/>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                        </w:pPr>
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                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-5"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>患者</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="11"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve">   </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-82"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:b/>
                                <w:bCs/>
                                <w:spacing w:val="-5"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t>高伟</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:hint="eastAsia" w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:b/>
                                <w:bCs/>
                                <w:spacing w:val="-5"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                                <w:lang w:val="en-US" w:eastAsia="zh-CN"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:b/>
                                <w:bCs/>
                                <w:spacing w:val="-5"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t>强</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="3"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve">   </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-5"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>性别</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="60"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="19"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-5"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
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                            <w:t>男</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="10"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-5"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>身份证</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="19"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:hint="eastAsia" w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="19"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                                <w:lang w:val="en-US" w:eastAsia="zh-CN"/>
                            </w:rPr>
                            <w:t xml:space="preserve">   </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-5"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t>4122719980712</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="43"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="65"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-5"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>出</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:hint="eastAsia" w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-5"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:lang w:val="en-US" w:eastAsia="zh-CN"/>
                            </w:rPr>
                            <w:t>院</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-5"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>日期</w:t>
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                            <w:rPr>
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                                <w:spacing w:val="-10"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:t xml:space="preserve"> </w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
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                            <w:t xml:space="preserve">    </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:hint="eastAsia" w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:b/>
                                <w:bCs/>
                                <w:i w:val="0"/>
                                <w:iCs w:val="0"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                                <w:lang w:val="en-US" w:eastAsia="zh-CN"/>
                            </w:rPr>
                            <w:t>2021/12/22</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:b/>
                                <w:bCs/>
                                <w:i w:val="0"/>
                                <w:iCs w:val="0"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t xml:space="preserve">  </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t xml:space="preserve">      </w:t>
                        </w:r>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:keepNext w:val="0"/>
                            <w:keepLines w:val="0"/>
                            <w:pageBreakBefore w:val="0"/>
                            <w:widowControl/>
                            <w:kinsoku w:val="0"/>
                            <w:wordWrap/>
                            <w:overflowPunct/>
                            <w:topLinePunct w:val="0"/>
                            <w:autoSpaceDE w:val="0"/>
                            <w:autoSpaceDN w:val="0"/>
                            <w:bidi w:val="0"/>
                            <w:adjustRightInd w:val="0"/>
                            <w:snapToGrid w:val="0"/>
                            <w:spacing w:before="230" w:line="360" w:lineRule="auto"/>
                            <w:textAlignment w:val="baseline"/>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                        </w:pPr>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-5"/>
                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>出院科室</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="48"/>
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                                <w:sz w:val="21"/>
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                                <w:sz w:val="21"/>
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                                <w:u w:val="single" w:color="auto"/>
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                            <w:t>神</w:t>
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                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
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                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:b/>
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                                <w:spacing w:val="-5"/>
                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:t>经</w:t>
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                                <w:spacing w:val="56"/>
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                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                                <w:b/>
                                <w:bCs/>
                                <w:spacing w:val="-5"/>
                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
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                            <w:t>外</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="53"/>
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                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:rPr>
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                                <w:b/>
                                <w:bCs/>
                                <w:spacing w:val="-5"/>
                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
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                            <w:t>科</w:t>
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                            <w:rPr>
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                                <w:spacing w:val="19"/>
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                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
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                            <w:t xml:space="preserve">  </w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="6"/>
                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:t xml:space="preserve"> </w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-5"/>
                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:t>病案号</w:t>
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                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-5"/>
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                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single"/>
                            </w:rPr>
                            <w:t xml:space="preserve">    200723</w:t>
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                        <w:bookmarkStart w:id="0" w:name="_GoBack"/>
                        <w:bookmarkEnd w:id="0"/>
                        <w:r>
                            <w:rPr>
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                                <w:spacing w:val="-5"/>
                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:t xml:space="preserve">24201 </w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:hint="eastAsia" w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
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                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single"/>
                                <w:lang w:val="en-US" w:eastAsia="zh-CN"/>
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                            <w:t xml:space="preserve">  </w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-5"/>
                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single"/>
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                            <w:t xml:space="preserve"> </w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="14"/>
                                <w:position w:val="-10"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:t xml:space="preserve"> </w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:hint="eastAsia" w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-5"/>
                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:lang w:val="en-US" w:eastAsia="zh-CN"/>
                            </w:rPr>
                            <w:t>住</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-5"/>
                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:t>院号</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-51"/>
                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:t xml:space="preserve"> </w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="7"/>
                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
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                            <w:t xml:space="preserve">           </w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:b/>
                                <w:bCs/>
                                <w:spacing w:val="7"/>
                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:b/>
                                <w:bCs/>
                                <w:spacing w:val="-5"/>
                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
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                            <w:t>200723242</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
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                                <w:bCs/>
                                <w:position w:val="2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
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                            <w:t xml:space="preserve">   </w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:position w:val="2"/>
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                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
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                            <w:t xml:space="preserve">    </w:t>
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                    <w:p>
                        <w:pPr>
                            <w:keepNext w:val="0"/>
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                            <w:sectPr>
                                <w:pgSz w:w="11900" w:h="16840"/>
                                <w:pgMar w:top="540" w:right="1460" w:bottom="0" w:left="1299" w:header="0" w:footer="0"
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                        <w:pPr>
                            <w:keepNext w:val="0"/>
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                                <w:sz w:val="21"/>
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                                <w:spacing w:val="-8"/>
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                                <w:szCs w:val="21"/>
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                            <w:t>现因</w:t>
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                                <w:spacing w:val="-53"/>
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                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
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                            <w:t xml:space="preserve">        </w:t>
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                        <w:r>
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                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-8"/>
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                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
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                            <w:t>保</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="44"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-8"/>
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                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
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                            <w:t>险</w:t>
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                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
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                            <w:t xml:space="preserve">         </w:t>
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                                <w:rFonts w:ascii="Arial" w:hAnsi="Arial" w:eastAsia="Arial" w:cs="Arial"/>
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                                <w:szCs w:val="2"/>
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                            <w:jc w:val="left"/>
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                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
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                                <w:szCs w:val="21"/>
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                            <w:t>需要，申请复印该患者如下病历资</w:t>
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                            <w:keepLines w:val="0"/>
                            <w:pageBreakBefore w:val="0"/>
                            <w:widowControl/>
                            <w:kinsoku w:val="0"/>
                            <w:wordWrap/>
                            <w:overflowPunct/>
                            <w:topLinePunct w:val="0"/>
                            <w:autoSpaceDE w:val="0"/>
                            <w:autoSpaceDN w:val="0"/>
                            <w:bidi w:val="0"/>
                            <w:adjustRightInd w:val="0"/>
                            <w:snapToGrid w:val="0"/>
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                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
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                                <w:szCs w:val="21"/>
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                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
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                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:t>共 1</w:t>
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                        <w:pPr>
                            <w:keepNext w:val="0"/>
                            <w:keepLines w:val="0"/>
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                            <w:t>打印金额：</w:t>
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                            <w:rPr>
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                            <w:t>34122719980712441X</w:t>
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                            <w:t>与患看大系</w:t>
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                                                    <a:noFill/>
                                                    <a:ln>
                                                        <a:noFill/>
                                                    </a:ln>
                                                </pic:spPr>
                                            </pic:pic>
                                        </a:graphicData>
                                    </a:graphic>
                                </wp:inline>
                            </w:drawing>
                        </w:r>
                    </w:p>
                    <w:p/>
                    <w:p/>
                    <w:p/>
                    <w:p/>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:line="56" w:lineRule="exact"/>
                        </w:pPr>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:sectPr>
                                <w:type w:val="continuous"/>
                                <w:pgSz w:w="11900" w:h="16840"/>
                                <w:pgMar w:top="540" w:right="1460" w:bottom="0" w:left="1299" w:header="0" w:footer="0"
                                         w:gutter="0"/>
                                <w:cols w:equalWidth="0" w:num="1">
                                    <w:col w:w="9141"/>
                                </w:cols>
                            </w:sectPr>
                        </w:pPr>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:before="54" w:line="219" w:lineRule="auto"/>
                            <w:ind w:left="1320"/>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                        </w:pPr>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-5"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>代理复印病案承诺书(有)</w:t>
                        </w:r>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:before="120" w:line="186" w:lineRule="auto"/>
                            <w:ind w:left="340" w:right="354" w:firstLine="379"/>
                            <w:jc w:val="both"/>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                        </w:pPr>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-13"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>本人已呈交患者亲笔授权委托书，保</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="12"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-14"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>证委托书真实，受托全权负责办理患者往</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="14"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-14"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>院病历复印相关事项，承诺承担患者病案</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="16"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-14"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>保密责在，进反者承担法律责行。</w:t>
                        </w:r>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:line="14" w:lineRule="auto"/>
                            <w:rPr>
                                <w:rFonts w:ascii="Arial"/>
                                <w:sz w:val="2"/>
                            </w:rPr>
                        </w:pPr>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="Arial" w:hAnsi="Arial" w:eastAsia="Arial" w:cs="Arial"/>
                                <w:sz w:val="2"/>
                                <w:szCs w:val="2"/>
                            </w:rPr>
                            <w:br w:type="column"/>
                        </w:r>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:before="41" w:line="222" w:lineRule="auto"/>
                            <w:ind w:left="1180"/>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                        </w:pPr>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-2"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>代理复印病案承诺书(无)</w:t>
                        </w:r>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:tabs>
                                <w:tab w:val="left" w:pos="237"/>
                            </w:tabs>
                            <w:spacing w:before="136" w:line="177" w:lineRule="auto"/>
                            <w:ind w:left="8" w:right="428" w:hanging="9"/>
                            <w:jc w:val="both"/>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                        </w:pPr>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="none" w:color="auto"/>
                            </w:rPr>
                            <w:tab/>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="none" w:color="auto"/>
                            </w:rPr>
                            <w:tab/>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-9"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="none" w:color="auto"/>
                            </w:rPr>
                            <w:t>因</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="1"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="none" w:color="auto"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="1"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t xml:space="preserve">                         </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="19"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve">   </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-9"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>原因，本</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-15"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>人无法呈交患者书面复议病案授权委托书，承诺</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-16"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>已</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-15"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>得到思者口头委托，受托全权负责办理患者住院病</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="17"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-13"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>历复印相关事项，承诺承担患者病案隐私保密和授</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="7"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-15"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>权委托而导致的全部法律纠纷责任。</w:t>
                        </w:r>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:sectPr>
                                <w:type w:val="continuous"/>
                                <w:pgSz w:w="11900" w:h="16840"/>
                                <w:pgMar w:top="540" w:right="1460" w:bottom="0" w:left="1299" w:header="0" w:footer="0"
                                         w:gutter="0"/>
                                <w:cols w:equalWidth="0" w:num="2">
                                    <w:col w:w="4241" w:space="100"/>
                                    <w:col w:w="4800"/>
                                </w:cols>
                            </w:sectPr>
                        </w:pPr>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:line="115" w:lineRule="exact"/>
                        </w:pPr>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:sectPr>
                                <w:type w:val="continuous"/>
                                <w:pgSz w:w="11900" w:h="16840"/>
                                <w:pgMar w:top="540" w:right="1460" w:bottom="0" w:left="1299" w:header="0" w:footer="0"
                                         w:gutter="0"/>
                                <w:cols w:equalWidth="0" w:num="1">
                                    <w:col w:w="9141"/>
                                </w:cols>
                            </w:sectPr>
                        </w:pPr>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:before="42" w:line="215" w:lineRule="auto"/>
                            <w:ind w:left="1630"/>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                        </w:pPr>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-15"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>代理人签名：</w:t>
                        </w:r>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:line="14" w:lineRule="auto"/>
                            <w:rPr>
                                <w:rFonts w:ascii="Arial"/>
                                <w:sz w:val="2"/>
                            </w:rPr>
                        </w:pPr>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="Arial" w:hAnsi="Arial" w:eastAsia="Arial" w:cs="Arial"/>
                                <w:sz w:val="2"/>
                                <w:szCs w:val="2"/>
                            </w:rPr>
                            <w:br w:type="column"/>
                        </w:r>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:before="70" w:line="189" w:lineRule="auto"/>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                        </w:pPr>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="仿宋" w:hAnsi="仿宋" w:eastAsia="仿宋" w:cs="仿宋"/>
                                <w:spacing w:val="-15"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>代理人签名：</w:t>
                        </w:r>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:sectPr>
                                <w:type w:val="continuous"/>
                                <w:pgSz w:w="11900" w:h="16840"/>
                                <w:pgMar w:top="540" w:right="1460" w:bottom="0" w:left="1299" w:header="0" w:footer="0"
                                         w:gutter="0"/>
                                <w:cols w:equalWidth="0" w:num="2">
                                    <w:col w:w="5731" w:space="100"/>
                                    <w:col w:w="3310"/>
                                </w:cols>
                            </w:sectPr>
                        </w:pPr>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:line="215" w:lineRule="exact"/>
                        </w:pPr>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:sectPr>
                                <w:type w:val="continuous"/>
                                <w:pgSz w:w="11900" w:h="16840"/>
                                <w:pgMar w:top="540" w:right="1460" w:bottom="0" w:left="1299" w:header="0" w:footer="0"
                                         w:gutter="0"/>
                                <w:cols w:equalWidth="0" w:num="1">
                                    <w:col w:w="9141"/>
                                </w:cols>
                            </w:sectPr>
                        </w:pPr>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:before="42" w:line="220" w:lineRule="auto"/>
                            <w:ind w:left="19"/>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                        </w:pPr>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-14"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>押金：</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="35"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-14"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>0</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="8"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve">     </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-14"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>领取日期：</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="104"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-14"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>2023-02-16</w:t>
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                    <w:p>
                        <w:pPr>
                            <w:spacing w:line="14" w:lineRule="auto"/>
                            <w:rPr>
                                <w:rFonts w:ascii="Arial"/>
                                <w:sz w:val="2"/>
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                        </w:pPr>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="Arial" w:hAnsi="Arial" w:eastAsia="Arial" w:cs="Arial"/>
                                <w:sz w:val="2"/>
                                <w:szCs w:val="2"/>
                            </w:rPr>
                            <w:br w:type="column"/>
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                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:before="130" w:line="184" w:lineRule="auto"/>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-7"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:t>申请人签字：</w:t>
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                    <w:p>
                        <w:pPr>
                            <w:sectPr>
                                <w:type w:val="continuous"/>
                                <w:pgSz w:w="11900" w:h="16840"/>
                                <w:pgMar w:top="540" w:right="1460" w:bottom="0" w:left="1299" w:header="0" w:footer="0"
                                         w:gutter="0"/>
                                <w:cols w:equalWidth="0" w:num="2">
                                    <w:col w:w="4251" w:space="100"/>
                                    <w:col w:w="4790"/>
                                </w:cols>
                            </w:sectPr>
                        </w:pPr>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:before="230" w:line="342" w:lineRule="auto"/>
                            <w:ind w:left="19"/>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                        </w:pPr>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-17"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:t>审批者：</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="64"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="101"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-17"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t>张</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-7"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-17"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t>梦</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-4"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-17"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
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                            <w:t>红</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="88"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="55"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-17"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:t>审批时间</w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-6"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t xml:space="preserve"> </w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                                <w:u w:val="single" w:color="auto"/>
                            </w:rPr>
                            <w:t xml:space="preserve">                 </w:t>
                        </w:r>
                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:before="1" w:line="218" w:lineRule="auto"/>
                            <w:ind w:left="19"/>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                        </w:pPr>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-7"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>审批部门盖章</w:t>
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                    </w:p>
                    <w:p>
                        <w:pPr>
                            <w:spacing w:before="162" w:line="193" w:lineRule="auto"/>
                            <w:ind w:left="19" w:right="534"/>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                        </w:pPr>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-5"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>说明：复印(复制)病历资料，申请人须提供出院记</w:t>
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                        <w:r>
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                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-6"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>录或出院结账清单或住院押金条，以便核查。</w:t>
                        </w:r>
                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
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                            <w:t xml:space="preserve"> </w:t>
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                        <w:r>
                            <w:rPr>
                                <w:rFonts w:ascii="宋体" w:hAnsi="宋体" w:eastAsia="宋体" w:cs="宋体"/>
                                <w:spacing w:val="-8"/>
                                <w:sz w:val="21"/>
                                <w:szCs w:val="21"/>
                            </w:rPr>
                            <w:t>调阅、复印所需法定材料参照规定执行。</w:t>
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                        <w:pgSz w:w="11900" w:h="16840"/>
                        <w:pgMar w:top="540" w:right="1460" w:bottom="0" w:left="1299" w:header="0" w:footer="0"
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                        <w:cols w:equalWidth="0" w:num="1">
                            <w:col w:w="9141"/>
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                <Words>371</Words>
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                                            <a:satMod val="135000"/>
                                        </a:schemeClr>
                                    </a:gs>
                                </a:gsLst>
                                <a:lin ang="16200000" scaled="0"/>
                            </a:gradFill>
                        </a:fillStyleLst>
                        <a:lnStyleLst>
                            <a:ln w="9525" cap="flat" cmpd="sng" algn="ctr">
                                <a:solidFill>
                                    <a:schemeClr val="phClr">
                                        <a:shade val="95000"/>
                                        <a:satMod val="105000"/>
                                    </a:schemeClr>
                                </a:solidFill>
                                <a:prstDash val="solid"/>
                            </a:ln>
                            <a:ln w="25400" cap="flat" cmpd="sng" algn="ctr">
                                <a:solidFill>
                                    <a:schemeClr val="phClr"/>
                                </a:solidFill>
                                <a:prstDash val="solid"/>
                            </a:ln>
                            <a:ln w="38100" cap="flat" cmpd="sng" algn="ctr">
                                <a:solidFill>
                                    <a:schemeClr val="phClr"/>
                                </a:solidFill>
                                <a:prstDash val="solid"/>
                            </a:ln>
                        </a:lnStyleLst>
                        <a:effectStyleLst>
                            <a:effectStyle>
                                <a:effectLst>
                                    <a:outerShdw blurRad="40000" dist="20000" dir="5400000" rotWithShape="0">
                                        <a:srgbClr val="000000">
                                            <a:alpha val="38000"/>
                                        </a:srgbClr>
                                    </a:outerShdw>
                                </a:effectLst>
                            </a:effectStyle>
                            <a:effectStyle>
                                <a:effectLst>
                                    <a:outerShdw blurRad="40000" dist="23000" dir="5400000" rotWithShape="0">
                                        <a:srgbClr val="000000">
                                            <a:alpha val="35000"/>
                                        </a:srgbClr>
                                    </a:outerShdw>
                                </a:effectLst>
                            </a:effectStyle>
                            <a:effectStyle>
                                <a:effectLst>
                                    <a:outerShdw blurRad="40000" dist="23000" dir="5400000" rotWithShape="0">
                                        <a:srgbClr val="000000">
                                            <a:alpha val="35000"/>
                                        </a:srgbClr>
                                    </a:outerShdw>
                                </a:effectLst>
                                <a:scene3d>
                                    <a:camera prst="orthographicFront">
                                        <a:rot lat="0" lon="0" rev="0"/>
                                    </a:camera>
                                    <a:lightRig rig="threePt" dir="t">
                                        <a:rot lat="0" lon="0" rev="1200000"/>
                                    </a:lightRig>
                                </a:scene3d>
                                <a:sp3d>
                                    <a:bevelT w="63500" h="25400"/>
                                </a:sp3d>
                            </a:effectStyle>
                        </a:effectStyleLst>
                        <a:bgFillStyleLst>
                            <a:solidFill>
                                <a:schemeClr val="phClr"/>
                            </a:solidFill>
                            <a:gradFill rotWithShape="1">
                                <a:gsLst>
                                    <a:gs pos="0">
                                        <a:schemeClr val="phClr">
                                            <a:tint val="40000"/>
                                            <a:satMod val="350000"/>
                                        </a:schemeClr>
                                    </a:gs>
                                    <a:gs pos="40000">
                                        <a:schemeClr val="phClr">
                                            <a:tint val="45000"/>
                                            <a:satMod val="350000"/>
                                            <a:shade val="99000"/>
                                        </a:schemeClr>
                                    </a:gs>
                                    <a:gs pos="100000">
                                        <a:schemeClr val="phClr">
                                            <a:shade val="20000"/>
                                            <a:satMod val="255000"/>
                                        </a:schemeClr>
                                    </a:gs>
                                </a:gsLst>
                                <a:path path="circle">
                                    <a:fillToRect l="50000" t="-80000" r="50000" b="180000"/>
                                </a:path>
                            </a:gradFill>
                            <a:gradFill rotWithShape="1">
                                <a:gsLst>
                                    <a:gs pos="0">
                                        <a:schemeClr val="phClr">
                                            <a:tint val="80000"/>
                                            <a:satMod val="300000"/>
                                        </a:schemeClr>
                                    </a:gs>
                                    <a:gs pos="100000">
                                        <a:schemeClr val="phClr">
                                            <a:shade val="30000"/>
                                            <a:satMod val="200000"/>
                                        </a:schemeClr>
                                    </a:gs>
                                </a:gsLst>
                                <a:path path="circle">
                                    <a:fillToRect l="50000" t="50000" r="50000" b="50000"/>
                                </a:path>
                            </a:gradFill>
                        </a:bgFillStyleLst>
                    </a:fmtScheme>
                </a:themeElements>
                <a:objectDefaults/>
            </a:theme>
        </pkg:xmlData>
    </pkg:part>
</pkg:package>
